Free INDIANA DEPARTMENT OF NATURAL RESOURCES - Indiana

RIDER TO SELF-BOND INDEMNITY AGREEMENT AND ABSOLUTE CORPORATE GUARANTY
State Form 51894 (8-04)

FOR OFFICIAL USE

SE-1 Form

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION

This endorsement is to be attached to and form a part of Self-Bond No. dated , executed by , As Principal, in favor of the State of Indiana, Department of Natural Resources, as obligee. It is herein understood and agreed that: (Check the appropriate boxes)

Initial submission of Self-Bond for Permit No. In the amount of ($ )

The amount of the above-described bond is hereby (Increased or Decreased)

($

) Dollars from the previous amount of:

($

) Dollars to a new total of:

($

) ,

as of the day of with respect to the following permit: Permit Number: Pit Name:

Other

Nothing herein contained shall vary, alter or extend any of the provisions, conditions or other terms of this Self-Bond Indemnity Agreement and Absolute Corporate Guaranty.

SE-1 Form Page 2 of 2

WITNESS OUR HANDS AND SEALS THIS

DAY OF

,

.

(Name of Principal) ATTEST: BY: (Signature)

(Typed or printed name and title)

(Attach a true and accurate copy of the authorization of the Board of Directors if someone other than the officers of the corporation who signed the Self-Bond Indemnity Agreement and Absolute Corporate Guarantee is signing this document.)

ACCEPTED:

, (Signed) Authorized Signature Division of Reclamation

RIDER TO SELF-BOND INDEMNITY AGREEMENT AND ABSOLUTE CORPORATE GUARANTY
State Form 51894 (8-04)

FOR OFFICIAL USE

SE-1 Form

INSTRUCTIONS
INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION

This endorsement is to be attached to and form a part of Self-Bond No. (1) dated (2) , executed by (3) , As Principal, in favor of the State of Indiana, Department of Natural Resources, as oblige. It is herein understood and agreed that: (Check the appropriate boxes below)

Initial submission of Self-Bond for Permit No. In the amount of (4b) ($ (4c) )

(4a)

The amount of the above-described bond is hereby (Increased or Decreased) (5a) (5b) (5c) (5d) (5e) (5f)

($

) Dollars from the previous amount of:

($

) Dollars to a new total of:

($

) ,

as of the (5g) day of with respect to the following permit: Permit Number: Pit Name: (5h) (5i)

Other (6)

Nothing herein contained shall vary, alter or extend any of the provisions, conditions or other terms of this Self-Bond Indemnity Agreement and Absolute Corporate Guaranty.

SE-1 Form Page 2 of 2

WITNESS OUR HANDS AND SEALS THIS

DAY OF

(7)

,

.

(8) (Name of Principal) ATTEST: BY: (9) (Signature) (10) (Typed or printed name and title)

(Attach a true and accurate copy of the authorization of the Board of Directors if someone other than the officers of the corporation who signed the Self-Bond Indemnity Agreement and Absolute Corporate Guarantee is signing this document.)

ACCEPTED:

, (Signed) Authorized Signature Division of Reclamation

INSTRUCTIONS FOR COMPLETING SE-1 FORM RIDER TO SELF-BOND INDEMNITY AGREEMENT 1) Self-bond number assigned by the Division of Reclamation upon approval of self-bond application. 2) Date of issue of Rider 3) Name of Principal 4) CHECK THIS BOX IF this if first submission of self-bond for a specific permit. Then complete 4a, 4b, & 4c. 4a) Permit number 4b) Type or print in words amount of self-bond 4c) Type or print numerals of amount of self-bond 5) Check and underline word in parenthesis in indicate INCREASE or DECREASE in the amount of self-bond 5a) Type or print in words amount of self-bond 5b) Type or print numerals of amount of self-bond 5c) Type or print in words total amount of self-bond previously applied to this permit 5d) Type or print numerals of total amount of self-bond previously applied to this permit 5e) Type or print in words the sum of 6b and 6d to make a new total 5f) Type or print numerals of the new total 5g) Date of increase or decrease in self-bond 5h) Permit Number 5i) Pit Name 6) Check this box to make any other changes to self-bond. Indicate change beside "Other" 7) Dated signed 8) Type or print name of Principal 9) Signature of authorized official of Principal 10) Type or print name and title of person signing rider for Principal